Spectrum Physical Therapy by miy51275

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									                              SPECTRUM Physical Therapy & Athletic Training, LLC
                                  Uniquely qualified to help patients break through physical barriers…

                      968 River Rd. 2nd Floor/Edgewater, NJ 07020   &    184 Central Ave. 1st. Floor/Old Tappan, NJ 07675
                        ph: (201) 937-3600 fax: (201) 731-5192                 ph: (201) 768-2000 fax: (201) 731-5192

                                   Outpatient Medical History/Screening Form

Patient Name: __________________________________ Spoken Language: __________________________
Emergency Contact: _____________________________ Telephone #: ______________________________
Family Physician/Internist: ________________________ Telephone #: ______________________________
Religious/Cultural Needs: NO ‭YES ‭Please Explain: ___________________________________________
Special Learning Needs: NO ‭YES ‭Please Explain: ___________________________________________

             Medical Information: To the best of your knowledge, do you have or have you had:

                                               YES NO                                                    YES NO


High Blood Pressure                             □ □            Spinal Cord Injury                          □   □
Chest Pain/Angina/Heart Attack                  □ □            Traumatic Brain Injury                      □   □
High Cholesterol                                □ □            Stroke                                      □   □
Pacemaker                                       □ □            Fractures                                   □   □
Emphysema/Asthma                                □ □               DATE:                            AREA:

Shortness of Breath                             □ □                 DATE:                          AREA:

Fainting Disorders                              □ □            Concussion                                □      □
Hepatitis                                       □ □            Osteoporosis                               □     □
Bleeding/ Bruising                              □ □            Multiple‭Sclerosis‭/‭Parkinson’s‭‭‭‭‭‭‭‭‭‭‭□     □
Anemia                                          □ □            Swelling of Extremities                    □     □
Diabetes                                        □ □            Artificial Joints                          □     □
Hypoglycemia                                    □ □            Muscle Pain/ Fatigue                       □     □
Cancer/ Tumors/ Growths                          □ □           Light-Headedness/ Dizziness                □     □
Blood Disorders                                 □ □            Night Pain                                 □     □
HIV/ AIDS                                       □ □            Night Sweats                               □     □
Seizures                                        □ □            Are You Pregnant?                          □     □
Anxiety/ Panic Attacks                           □ □           Bladder/ Bowel Incontinence                □     □
Depression                                       □ □           Other:                                     □     □
Kidney Disease/ Stones                           □ □           Height:                  Weight:

Do you cough or choke when                       □ □           UNDER 18 ONLY:
you eat or drink?                                              Immunizations Current                        □ □

                                                                                                                            1
PAIN:
RATE YOUR PAIN: (0-10) ____________________________
                  (none) 0 1 2 3 4 5 6 7 8 9 10 (unbearable)
LOCATION OF PAIN: _____________________________________________________________

FALL RISK ASSESSMENT:                                                       NUTRITIONAL SCREENING:
                                                        Yes No                                                                       Yes No
Have you fallen in the past                                                 Diarrhea/ Nausea/ Vomitting                               □‭‭□
6 months?                                                 □‭‭□
Do you experience dizziness or                                              Unexplained Weight Loss?                                  □‭‭□
Vertigo?                                                  □‭‭□              (>5% in last 30 days)
Are you afraid of falling?                                □ □               Loss of appetite/ aversion to food?                       □‭‭□
Have you recently felt unsteady on                                          Decrease in food intake?
your feet? Or in your wheelchair?                          □‭‭□             (<50% for 3 days or more)                                □‭‭□
Do you have vision problems                                                 History of eating disorder?                              □‭‭□‭‭
that are not corrected by glasses?                         □‭‭□
Do you use sedatives that affect                                            Change in bowel habits?                                  □‭‭□
your arousal during the day?                              □‭‭□
Do you have a lower extremity                                               CURRENT MEDICATION: (List Below)
Disability that affects walking?                           □‭‭□             List Attached        □




Allergies: A. To Medications: __________________________________________________________
           B. To Other Substances: ______________________________________________________
Surgery (S) Include Dates: _____________________________________________________________
X-Rays, MRI, CAT SCAN (include Area & Date): __________________________________________
What are your treatment goals?: _________________________________________________________

If you need information regarding Advanced Directives, please contact the site Admission/Office
Assistant.

PATEINT SIGNATURE: ___________________________________ DATE: ________________________
Relationship if other than patient/ parent/ guardian if minor: ______________________________________

This information will be used as a guide to your treatment plan. If you need any medical follow-up, please contact your physician.

                                                             For office use only
Patient has been identified as a fall risk: yes no (yes if patient answered yes to 3 or more fall risk questions above)
If yes, fall prevention program has been implemented: yes         no
Patient has been identified as a nutrition risk: yes no        Physician has been notified: yes   no
Patient has been identified as requiring social service referral: yes no

SIGNATURE: _______________________________________        DATE: _________________________________
                                   (Therapist has reviewed medical history form with patient)
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